A home health nurse is teaching a client about home safety.

Which of the following statements by the client indicates an understanding of the teaching? (Select all that apply.).

The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

“The higher the score, the higher the pressure injury risk”: This statement is incorrect.

The lower the score on the Braden scale, the higher the risk for pressure injury.

“Each element has a range from one to five points”: This statement is incorrect.

Each element has a range from one to four points, except for friction/shear which has a range from one to three points.

“The client’s age is part of the measurement”: This statement is incorrect. Age is not one of the elements measured by the Braden scale.

Leaving the drain until the end of the shift is not appropriate because it could lead to complications such as:

• Hematoma formation:Blood accumulation in the tissues surrounding the drain can put pressure on surrounding structures,potentially impairing blood flow and causing tissue damage.
• Infection:A reservoir containing blood provides a favorable environment for bacterial growth,increasing the risk of infection.
• Drain occlusion:Clotted blood can block the drain,preventing effective drainage and leading to fluid buildup and potential infection.
• Decreased wound healing:Excessive blood loss can delay wound healing by depriving the tissues of necessary oxygen and nutrients.

Removing the drain without the surgeon's order is not appropriate because:

• Premature removal:It could disrupt the healing process and lead to complications such as fluid collection or infection.
• Assessment limitation:Removing the drain would eliminate the ability to monitor ongoing blood loss and could mask potential complications.

A Jackson-Pratt drain works by creating suction when the bulb is squeezed and emptied¹. The bulb should be emptied before it is more than half full to avoid the discomfort of the weight of the drain pulling on the internal tubing and to maintain the suction

Notifying the surgeon about the blood loss is wrong because it is not an urgent situation unless there are signs of excessive bleeding, such as bright red blood, clots, or a sudden increase in the amount of drainage²³. The surgeon should be notified if the drainage is more than 100 ml in 24 hours or if the color changes from serosanguineous (pink) to sanguineous (red)